Access to Care Survey

Local Transportation Resources

The Access to Care action team is working with the Tri-County Council for Southern Maryland to explore innovative transportation solutions to increase access to healthcare locally. As part of this process the team is compiling an inventory of local transportation resources to help identify gaps. Please answer the following questions on behalf of your organization.

For more information on the Access to Care action team and this initiative please visit: http://healthystmarys.com/access-to-care/

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* 1. Contact Information

Name

Organization Name

E-mail or Phone Number

Is this organization an HSMP partner?

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* 2. Does your organization offer transportation services or support?

Yes

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* 3. What are the criteria for utilizing these transportation services (e.g., Medicaid, no registered vehicle in MD, enrolled in a specific program, etc.)

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* 4. Please indicate the number of the following transportation resources that your organization currently has.

Vehicles equipped with a wheelchair lift

Vehicles not equipped with a wheelchair lift

Drivers

Seating capacity

Other (please describe)

Access to Care Survey

Local Transportation Resources

Question Title

* 1. Contact Information

Question Title

* 2. Does your organization offer transportation services or support?

Question Title

* 3. What are the criteria for utilizing these transportation services (e.g., Medicaid, no registered vehicle in MD, enrolled in a specific program, etc.)

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* 4. Please indicate the number of the following transportation resources that your organization currently has.

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* 5. Do you have any specific concerns about transportation and access to healthcare in St. Mary's?

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* 6. Additional comments: